Pediatric Coding Alert

One of the most challenging problems pediatric coders encounter is lack of a specific diagnosis. It is in part a reflection of the uniqueness of pediatrics. Parents bring in their children for minor or vague problems because theyre children. A small child cant speak for himself about what hurts. In general, no one would argue with a parent who says, Better safe than sorry.

However, the fact remains that managed care companies -- and the computers that decide whether to pay or reject claims -- can be picky when it comes to the word unspecified.

A particularly common problem is 493.9 , the diagnosis code for asthma, unspecified, says Sheila Hume, insurance manager for Raleigh Group Pediatrics, a four-pediatrician, six-nurse practitioner practice in Memphis, TN. We get a lot of kick-outs on these asthma children, says Hume. Its because in pediatrics, we see these kids a lot, she says. Parents tend to bring kids in more than adults would go for something.

With a few insurance companies, says Hume, you have to be specific to get paid. However, the only alternatives for diagnosis codes for these children are not appropriate, she says. The pediatrician cant say for sure that they have extrinsic (allergic) asthma (493.0), intrinsic (pathophysiological) asthma (493.1), or chronic obstructive asthma (493.2). But unspecified asthma, which could included suspected allergic when the allergen is not known yet, is the most accurate diagnosis -- so thats the one the pediatrician uses, says Hume.

Important: All of the asthma diagnosis codes require a fifth digit of 0 or 1; 0 is for without mention of status asthmaticus, 1 is with status asthmaticus. So actually, in the case of 493.9 -- asthma, unspecified, -- you would need to have 439.90 or 439.91. If there is no fifth digit, that is another reason that the insurance companies might not be paying.

If you still have a problem, you should contact the insurance company and ask which code to use to get the visit reimbursed. You should appeal to the medical director if necessary. Asthma is an example in which unspecified is accurate and appropriate.

Not everyone has problems with the unspecified codes, however. Sometimes we use it for asthma, and often for the ingestion of an unspecified drug, says Marsha Bates, insurance clerk for North Mississippi Pediatrics in Tupelo, MS.. If its unspecified, you have to put unspecified, says Bates, whose seven-pediatrician practice does sometimes have to send a copy of the doctors notes in order to get these codes paid. But that always works, she says. And we have no problem whatsoever with 977.9, she says. 977.9 is for poisoning by unspecified drug or medicinal substance.

The trick to getting unspecified diagnosis codes paid is to call the managed care company, and sometimes even to send the records, Hume and Bates agree.

Its not only a matter of what the pediatrician is able or not able to diagnosis. The fact is that the codes just dont cover everything. Take the unspecified drug ingestion. The mom may know what the child took but there may be no code for that substance. If the clerks cant find it, we use unspecified, says Bates.